The Kansas CCL 029 form is a crucial document required by the Kansas Department of Health and Environment for maintaining the health records of children in licensed child care facilities. This form ensures that parents provide essential medical information, including immunization history and any specific health concerns, for each child in care. Completing this form accurately is vital for the well-being of your child while in a child care setting.
To fill out the Kansas CCL 029 form, please click the button below.
When working with the Kansas CCL 029 form, several other forms and documents are commonly utilized to ensure comprehensive care and compliance in child care settings. These documents help facilitate communication between parents, caregivers, and health professionals, ensuring that all necessary information is available for the child's well-being.
These documents collectively contribute to a safe and nurturing environment for children in care. By ensuring that all necessary information is readily available, caregivers can respond effectively to the needs of each child, fostering their health and well-being.
The Kansas CCL 029 form is a medical record required by the Kansas Department of Health and Environment for all children in licensed child care facilities. This form collects essential health information, including immunization history, medical conditions, and emergency contact details.
Parents or guardians must complete the CCL 029 form for each child enrolled in a licensed child care facility. This requirement applies to all children, including the provider's own children.
The form requires the following information:
Yes, a Kansas Certificate of Immunizations (KCI) can be substituted for the immunization section of the CCL 029 form. However, it must be attached to the completed medical record.
If your child has any medical conditions or allergies, you must provide detailed information on the form. This includes any medications your child takes and special instructions for their care in the child care facility.
The Child Health Assessment is a separate section of the CCL 029 form that must be completed by a nurse approved by the Kansas Department of Health and Environment or a licensed physician. This assessment evaluates the child's overall health and any specific needs.
The completed CCL 029 form should be submitted to the child care facility where your child is enrolled. It is essential to ensure that all sections are filled out accurately to avoid delays in your child's enrollment.
Failure to complete the CCL 029 form may result in your child being unable to enroll or continue in the licensed child care facility. It is crucial to provide this information to ensure the health and safety of all children in care.
Understanding the Kansas CCL 029 form is crucial for parents and guardians enrolling their children in licensed child care facilities. However, several misconceptions can lead to confusion. Here’s a breakdown of some common misunderstandings:
Clearing up these misconceptions can help ensure that parents are well-prepared for their child's care in licensed facilities. Understanding the requirements of the Kansas CCL 029 form is essential for a smooth child care experience.
The Kansas Certificate of Immunization (KCI) is a document that serves a similar purpose to the Kansas CCL 029 form. Both documents are required for children attending licensed child care facilities. The KCI provides a comprehensive record of a child’s immunizations, which can be substituted for the immunization section of the CCL 029 form. Parents can present the KCI to demonstrate compliance with vaccination requirements, ensuring that children are protected against various diseases while in care.
The Authorization for Emergency Medical Care form (CCL. 010) is another important document related to child care. This form allows parents or guardians to give permission for medical treatment in case of an emergency. Like the CCL 029 form, it emphasizes the importance of having up-to-date medical information readily available for caregivers. Both forms require signatures from parents or guardians, highlighting their role in ensuring that children receive appropriate care during emergencies.
The Kan-Be-Healthy Assessment Form is also comparable to the CCL 029 form. This form is used to assess a child's overall health and development, similar to the Child Health Assessment section of the CCL 029. It is specifically designed for children in licensed child care settings and must be completed by a qualified health professional. Both forms aim to ensure that children’s health needs are documented and addressed, promoting a safe environment for their growth and development.
The California Power of Attorney for a Child form is a necessary document that allows parents to delegate decision-making authority to a trusted individual. This type of form becomes crucial in circumstances where a parent might be unavailable, such as during illness or travel. For those interested in understanding this process better, you can find more information at https://californiapdf.com/editable-power-of-attorney-for-a-child.
Finally, the School Health Assessment Form is relevant for school-age children and serves a similar function as the CCL 029 form. This document provides a health evaluation required for children attending school, just as the CCL 029 form does for those in child care. Both forms collect essential health information and require input from health professionals, ensuring that children's health is monitored and managed appropriately across different settings.
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CCL. 029
Kansas Department of Health and Environment
Rev. 8/2011
Bureau of Child Care and Health Facilities
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone (785) 296-1270 Fax (785) 296-0803
Website: www.kdheks.gov/kidsnet
MEDI CAL RECORD FOR ALL CHI LDREN I N CHI LD CARE FACI LI TI ES,
I NCLUDI NG PROVI DER’S OWN CHI LDREN
Parents are to complete the Medical Record and the History of I mmunizations for each child in licensed child care facilities. The Medical Record, History of I mmunizations, and Child Health Assessment are transferable w hen the child moves to another licensed child care facility.
Child’s First Day in Child Care
Name of Child Care Facilit y
Child’s Name
Date of Birth
Gender
First
Last
MM/ DD/ YYYY
M/ F
Parent/ Guardian I nformation
Name
Home Address
Street
City
Zip Code
Home Phone Number
Work Address
Work Phone Number
Cell Phone Number
E-mail Address
Best way to contact
Names and ages of children in family
Persons aut horized to pick up the child or to notify in case of emergency. I nclude name, address, and telephone number. Attach an additional page, if necessary.
Child’s Physician
Phone Number
Child’s Dentist
Hospital Preference (for emergencies)
Has your physician approved the use of any non-prescription medications for your child such as acetaminophen, cough
syrup, or ointments that can be given by the child care provider? No Yes, as follows:
Does your child have any of the following conditions (yes or no) ? I f yes, provide information on Aut horization for Emergency Medical Care form CCL. 010.
Allergies
Frequent sore throats/ colds
Ear Aches
Asthma
Speech, Visual, Hearing
Diabetes
Epilepsy/ Seizures
Other
I f yes answered to any above, please provide additional information
Have there been major changes at home that might affect your child in care?
No
Yes, as follows:
Please provide additional information or special instructions that will help t he person caring for your child.
Parent/ Guardian Signature:____ ____________ ___________________ ______ Date:_________ ____
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History of I mmunizations
Required for all children in child care facilities, including the provider’s ow n children. A Kansas Certificate of I mmunizations ( KCI ) may be substituted for this form and attached to the completed Medical Record.
Child’s Name:
Date of Birth:
Section I . For a recommended schedule of immunizations, refer to the current schedule published by the Advisory Committee on I mmunization Practices ( ACI P) .
Vaccine
Record the Month. Day and Year that each Dose of Vaccine w as Received
1 st
2 nd
3 rd
4 th
5 th
6 th
DTaP/ DT/ Td/ Tdap (Diphtheria,
Tetanus, Pertussis)
Polio
MMR (Measles, Mumps, and Rubella
combined)
HBV (Hepatitis B Vaccine)
Hx of Disease:
Date of I llness:
Varicella (Chicken Pox)
Physician Signature
HI B (Hemophilus I nfluenzae Type B)
PCV7 (Pneumococcal Conjugate)
HEP A (Hepatitis A)
Rotavirus * * Recommended < 8 mo of
age; not required
I nfluenza( Flu) * * Recommended
annually > 6 mo of age; not required
Section I I .
Complete this section only if your child is exempted from the law requiring immunizations [ K.S.A. 65 - 508( d) ] .
Section I I . Complete Section below only if your child is exempted from law s requiring requiring
The following two options are the ONLY exemptions allowed by law. Please check either ( A) or ( B) below and immunizations [ K.S.A. 65 - 508( d) and K.S.A. 65 - 519( c) ]
complete as required:
( A) Certification from licensed physician stating that immunization w ould endanger child’s life:
Exempt from following immunizations:
DTP
Pertussis Only ____Tetanus ____Polio
MMR
Rubella Only
Hep A
Hep B
Hib
_PCV7 ____Ot her
Physician’s Signature (required): ________________________________________________Date:_______________
( B) My child is exempt under the law from immunizations. As the Parent or Legal Guardian, I state that I am an adherent of a religious denomination w hose teachings are opposed to immunizations.
Section I I I .
Parent/ Guardian Signature:____ ____________ ___________________ ______ Date:_________ _______
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CCL. 029a
Rev. 08/2011
Child Health Assessment
The Child Health Assessment form is to be completed and signed by a nurse approved by KDHE to perform Child Health Assessments or a Licensed Physician. I f a Physician Assistant (PA) completes the Child Health Assessment, t he signature of the Licensed Physician authorizing the PA is to be included at the bottom of this form.
A Child Health Assessment, recorded on a KDHE Form or other acceptable Forms mentioned below, is required for all children including children of the provider or staff in Licensed Day Care Homes, Group Day Care Homes, Child Care Centers and Preschools. A Kan-Be-Healthy Assessment Form is a KDHE Form and is acceptable, a Physician Health Assessment Form is acceptable, and a School Health Assessment Form is acceptable for school-age children or youth. The Health Assessment Form used should be attached to the KDHE Medical Record Form (CCL. 029) .
Child’s Name_______ __ ___________________ _____________ Date of Birth_________ __________
Health history and medical information pertinent to routine child care and emergencies (describe, if any):
None
Do you see this child for regular health supervision:
Yes No
Allergies to food or medicine ( describe, if any):
List current medications (if any):
Length/ Height: ______ I N/ CM
% I LE_______
Weight: _____ LB/ KB % I LE_______
Physical Examination
I f Normal
I f Abnormal - Comments
Head/ Ears/ Eyes/ Nose/ Throat
Teeth
Cardio/ Respiratory
Abdomen/ GI
Genitalia/ Breasts
Extremities/ Joints/ Back/ Chest
Skin/ Lymph Nodes
Neurologic & Developmental
Screening Tests
Screening Date
Note Here if Results are Pending or Abnormal
Lead
Anemia (HGB/ HCT)
Urinalysis (UA)
Hearing
Vision
Health Problems or Special Needs, Recommended Treatment/ Medications/ Special Care (Attach additional sheets if necessary)
Signature of Licensed Physician or Nurse approved for Child Health Assessments
Date
Print the Name of the I ndividual Signing Above
Address
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